Hair Transplant - The 60 Years of Evolution
Punch Graft
The world first hair transplant surgery for Androgenetic Alopecia was performed by Dr. Norman Orentreich in 1952. The early procedure involved punching out a round piece of hair-bearing tissue 4-mm in diameter directly from the back of the scalp. Such graft contained about 20 hair and produced a rather pluggy appearance. This Punch Graft technique remained the standard for 20 years.
 
Strip Harvesting
In 1984 a strip of tissue was excised from the donor area and then dissected into smaller grafts containing about 6 hair ( Mini Graft ). Later the size of the grafts was further reduced to contain just 1-2 hair Micro-Graft.
The main drawback of strip is a linear donor scar. The Trichophytic Closing Technique was introduced by Dr Marzola ( Australia ) and Dr Frechet ( France ) in 2005 to minimize the donor scar.
Mixed Grafting
Surgeons began to combine both mini- and micro-grafts in their procedures. The small micro-grafts were use to soften the frontal hairline, while the larger mini-grafts were placed in the center of the scalp to create a high density appearance. Mixed grafting slowly replaced the plug technique and became the new standard in the 1990’s. However the result is still not natural on close inspection.
Follicular Unit Transplant - FUT
In 1994 Dr. Bobby Limmer (USA) first described the technique for isolating Follicular Units ( FU ) using a microscope. This process enables the removal of redundant tissue. The grafts were kept as small as possible while preserving the integrity and all growth elements. Transplanting exclusively FUs produced far superior results. Since 2000 FUT has become the gold standard of surgical hair restoration.
 
Follicular Unit Extraction - FUE
FUE was introduced as an alternative to strip harvesting in FUT. It was similar to Punch Graft except a smaller 0.8 to 1.0-mm diameter punch was used. Follicular units were directly punched out one-by-one.
The first surgeon performing FUE was believed to be Dr Wood in Australia, who kept his technique a secret. Dr Inaba ( Japan ) described the same technique in his 1996 textbook. In the United States FUE was introduced by Dr. Rassman and Bernstein in 2002. It gained popularity all over the world due to over-promising publicity.
 
Dense Packing
Dr Jerry Wong of Canada pioneered dense packing and megasession, the hallmarks of Ultra-Refined FUT. Over the last 5 years the number of graft has increased from 3,000 (megasession) to over 5,000 (gigasession). In just one session a large area can be covered by a high density of grafts ( 40-60 FUs/sq.cm ).
 
Invisible Scar - Trichophytic Closure
Those who tell you that strip harvesting leaves a horrible scar is out of their mind! Dr Frechet, Dr Marzola, and Dr Rose in 2005 introduced the Trichophytic Closing Technique. This allows hair to grow through the scar as camouflage so that in most cases the scar is minimal if not invisible.
 
Hair Transplant - Chronological Development
1822
J. Dieffenbach of Wurzburg, Germany had written thesis about concept of autotransplantation of hair, feather, and skin in animals and fowl. Success with the use of goose quills as trephines.
1930
Okuda had written a paper in Japanese Journal of Dermatology on punch grafting of hair for alopecia on the scalp, eyebrow, moustache and pubic areas.
1950's
Dr. Norman Orentreich, the Father of Hair Transplantation, discovered the principle of donor dominance. In 1952 he relocated balding resistant hair follicles (10 4mm grafts) from the back and sides of the head to the balding scalp for MPB. His first paper appeared in NewYork Academy of Sciences in 1959. He established the first medical hair clinic in USA. Director of the Orentriech Foundation for the Advance of Science.
1960's
With this hair transplantation concept, physicians began to perform hair transplants for cosmetic improvement. And like most new developments, the first attempts were less than perfect. Doctors were successful in transplanting hair from the sides and back of the head to the top, but the results looked unnatural and obvious. These older and obsolete methods of hair transplantation practiced in the 1960's and 1970's nearly always resulted in a "clumped" or "bristle brush" appearance. The "Barbie Doll" appearance of hair transplant plugs (round grafts containing generally 15-25 or more hairs) is unfortunately nearly always quite conspicuous, and worse, permanent
Micrografting and minigrafting were introduced by Sam Ayres III using 1.5 to 2.0mm punch. He also described the term “follicular units”. He omitted pressure bandage in his patients.
1970's
1973 O’Tar Norwood introduced the classification of MPB, co-founder with Dow Stough of the International Society of Hair Restoration Surgery, and later founded the Hair Transplant Forum International (1990-1995)
1967 Richard Shiell pioneered Hair Transplantation in Australia.
Marcelo Gandelman pioneered the use of motorized punch transplantation.
1980's
Obviously these procedures required dramatic improvements. Over the course of years the technique of hair transplantation evolved. During the 1980s, minigrafts ( smaller clumps containing 5-8 hairs ) were an improvement, but only served to generate smaller "plugs". Indeed, many hair restoration procedures involve the repair and/or hairline camouflage of these "plugs" or "minigrafts". Even more unfortunately, some hair transplant doctors still utilize these larger grafts.
As techniques have improved, the grafts have become smaller and the number transplanted per session has increased. Today most hair transplant surgeons use grafts that have from one to eight hairs, with 200 to 800 grafts transplanted in each session. Although this is a major improvement over the larger grafts, this procedure still can produce a slightly unnatural look.
1981 Rolf Nordstrom described the use of single hair shafts and used the term micrograft for the first time.
1982 Pierre Bouhanna developed the Photorichogram.
1988 Robert Limmer carried out the first pure follicular unit transplant.
The next evolution in surgical hair restoration techniques is called follicle-unit micrografting, and it has revolutionized the approach to many forms of hair loss. With this method, many hundreds or thousands of tiny, living grafts containing only one, two, three or four hairs are inserted in closely spaced fashion over the entirety of the bald and thinning areas. These follicle-unit micrografts, which approximate the one to four hairs which naturally originate from each of your original follicles, result in a very natural, aesthetic appearance. Randomly-spaced single hair micrografts are used in the very front of the hairline to create an especially pleasing, feathered hairline.
1992 Patrick Frechey described Scalp Extension.
1990's
To be continued ...
Reference
Unger & Shapiro, Hair Transplantation, 4th Edition, Marcel Dekker 2004
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